Tactical EMS

Redefining 'All Clear' in active-shooter response

Once the shooter is dead or apprehended, the top mission for police and EMS is to stop the dying from bleeding and airway compromise

Law enforcement and EMS have been working side-by-side for many decades using a long-standing system of integration that, for the most part, works well. Actual and potentially violent scenes are everyday occurrences in many EMS systems and it is universally understood that the scene should be secured by law enforcement before EMS enters to begin patient assessment and treatment.

A secure scene happens most of the time, but not always. As a general rule, potentially hostile or violent scenes should have law enforcement first on scene dealing with the situation while EMS crews are standing by, ready to enter the scene after they get the "all clear."

"Clear" or "secure" are relative terms of course, as no scene is ever 100 percent safe and free of potential threats.

Incidents that involve an active threat, such as a shooter or shooters, usually dictate the need for EMS crews to stage a safe distance away until they are given the all clear. This makes sense for most situations.

Where the "all clear" scene gets cloudy though is during active-shooter incidents that statistically are resolved very quickly — most within a few minutes according to an FBI study that looked at 160 active shooter incidents over a 14-year period. More than two-thirds of active shooter incidents end in the perpetrator fleeing the scene, killing himself, being killed by police or being subdued by someone before law enforcement arrives.

Aggressive law enforcement actions have ended at least 28 percent of active shooter incidents, most within five minutes. Law enforcement universally moves quickly and aggressively toward the threat in an attempt to disrupt, distract, and eliminate the threat.

While law enforcement actions are swift and focused at active shooter incidents, many have seen a delay in getting medical assets to severely injured. The delay is not because of the time used to mitigate, isolate or neutralize the threat.

Not having a unified command is a top cause of delayed medical response. The July 2012 Aurora, Colorado, theater shooting response had separate fire and law enforcement command posts. Communication between the disciplines was a problem, and it was quite some time until fire/EMS knew the shooter was in custody.

In other active shooter incidents, the delay in getting medical assets to the victims was because of the time-consuming effort to do an extensive clearing operation of the entire school, office building, business complex or mall.

There is a perception that clearing requires law enforcement to check every room, cabinet, bathroom, closet, barrel, dumpster, desk, storage area, attic, basement or garage before calling an "all clear." This process spends critical minutes, even hours, allowing casualties to possibly bleed to death from treatable wounds.

What does this mean for first responders?
Critically injured victims need medical care fast, especially if the mechanism is ballistic penetrating trauma. There is a very high likelihood the single, male shooter (all but six of the 160 active shooters in the FBI research were male) is either dead or has fled the scene before any EMS responders arrive.

The other profound piece of statistical evidence in the FBI report is that all but two of the 160 incidents were perpetrated by a single shooter. It is highly unlikely that there are other shooters. But one cannot be certain enough to allow EMS personnel to enter without law enforcement sweeping the area first and providing force protection.

The primary mission for law enforcement is to stop the killing. Once that occurs, the mission for everyone including law enforcement is to stop the dying.

This is best done by reducing the time between threat elimination and medically trained rescuers on scene, or in some cases, bringing casualties to a treatment area. Time is the critical factor here.

A significant time delay is a death sentence to many trauma victims. This was painfully obvious in the Columbine attacks where it took hours before medical responders entered the scene. EMS rescue task force members need to be ready and properly equipped to get into the scene quickly and aggressively with law enforcement escort as soon as the threat has been mitigated.

Redefining "clear" during an active-shooter incident
In the simplest terms, clear means no bad guys, no bombs in the area where the victims are with safe access and egress passage for responders. Medical personnel need a safe corridor to move freely within certain designated areas.

Law enforcement still needs to protect a perimeter and post security for a possible secondary threat. In incidents such as the Orlando, San Bernardino, Aroura and Sandy Hook shootings, the vast majority of casualties were in a single area.

There are other methods of moving rescue task force teams around with a protective envelope of law enforcement escorts. The RTF model makes sense when casualties are geographically distributed and law enforcement has not had time to do an extensive room-by-room clearing of potential threats. The RTF model still allows for relatively expedient, but protected access to casualties by medical first responders.

Top trends in active-shooter response
The other encouraging trend in law enforcement is the training and equipping of line officers in self-care and buddy care, primarily focused on hemorrhage control. There have been several documented saves by law enforcement by initiating aggressive point-of-wounding care before EMS arrival.

Our experience in hundreds of exercises, including Urban Shield, the largest multi-discipline tactical exercise in the United States has seen another encouraging trend. Over the last 10 years of Urban Shield, we have witnessed an ever-increasing capability of the tactical teams in initiating life-saving interventions on casualties after the threat has been mitigated, but before medical assets are brought into the scene.

Best practices have been established with the more enlightened tactical teams starting casualty care and escorting the EMS responders into the scene quickly, while still offering scene security and force protection. Law enforcement, in addition to maintaining a security posture, has assisted in moving casualties, therefore minimizing the time delay in transporting patients to trauma centers.

There are still some in fire and EMS who are hesitant to enter chaotic, semi-secured scenes. We need to use statistical evidence and law enforcement intelligence to make informed decisions to drive EMS decision-making. We are not talking about the reckless abandonment of safety.

For life-saving interventions to happen at the point of wounding, law enforcement needs to do these four things.

Eliminate the threat.

Do a quick clear to ensure no bad guys, no bombs.

Establish a safe corridor for medical responders.

Offer necessary protection.

Police and EMS must stop the killing to stop the dying. (Image courtesy Josh Kennedy)

This is not a radical concept. The U.S. Fire Administration, Department of Homeland Security, The International Association of Fire Chiefs, and The International Association of Fire Fighters have published position papers and guidelines to support this concept.

By working together, training together and developing safe, but flexible policies, law enforcement and EMS responders can safely do what they are trained to do — stop the killing to stop the dying.

About the author

Jim Morrissey is a former Tactical Paramedic for the San Francisco FBI SWAT team and the founder of the Tactical Medical Association of California (TMAC). Jim is also the Terrorism Preparedness Coordinator for the Alameda County EMS Agency. Jim has a master’s degree in Homeland Security from the Naval Postgraduate School in Monterey, CA. Jim's column is brought to you by Bound Tree Federal, specializing in emergency medical equipment, supplies and pharmaceuticals for federal government organizations.